Online Registration Form - South View Partnership

See our practice leaflet, and visit our About Our Surgery section for general information. Please complete this form for each new patient.

We value the information you give us, as it helps us to get to know you, and to understand your health needs better. If you need help or support completing this form, please ask! Thank you.

Personal Identification

Title

Please specify

NHS Number

Name

First Last

Previous Surname Optional

Date of Birth

Gender

Female

Male

Town of Birth

Country of Birth

Address

Street Address Address Line 2 City Postcode

Occupation

Contact Number

Email Address

Enter Email Confirm Email

If applicable, school currently attended Optional

Patient Communication Preferences

The surgery may need to contact you with regards to appointments, health services, screening etc.

Please let us know how you would like us to keep in touch with you

Mobile

Text

Letter

Any method

Alternatively, if you would like us to only use a specific method please let us know.

How do you communicate?

Please let the surgery know if you require information in a different format

Large Print Optional

British Sign Language Interpreter Optional

Language Interpreter Optional

Please specify the Language

Please help us trace your previous medical records by providing the following information:

Are you from the UK, from abroad or returning from the Armed Forces?

Abroad

Returning from the Armed Forces

Your previous address in the UK

Street Address Address Line 2 City Postcode

Name of doctor while at that address

Address of previous doctor

Street Address Address Line 2 City ZIP / Postal Code

Your first UK address where registered with a GP

Street Address Address Line 2 City Postcode

If previously resident in UK, date of leaving

Date you first came to live in the UK

Address before enlisting

Street Address Address Line 2 City Postcode

Service number

Enlistment Date

Carer Information

Are you a carer?

Yes

Please also complete a ‘Carers Identification & Referral form’ from the practice.

Does someone care for you?

Yes

Carer's Name

First Last

Carer's Contact Number

Next of Kin (emergency contact)

Next of Kin/Emergency contact's Title

Next of Kin/Emergency contact's Name

First Last

Next of Kin/Emergency contact's Contact Number

Relationship to you

Consent to discuss health issues

Yes

Online access

Patients aged 13 plus are encouraged to use the NHS APP (available to download from your app store).

This will enable you to view your medical records, order repeat prescriptions, make routine appointments and submit eConsult (online consultations) as well as self-help advice. You will be able to verify your own ID using your passport or driving licence.

Please confirm if you will be using our online services.

Yes

Summary Care Record

Your Summary Care Record is a summary of your GP medical records. When you are treated away from your usual doctor’s surgery, the health care staff can see your medical records which may speed up your care and make sure you are given the right medicines and treatment.

I consent to share my summary care record.

Yes

You can share more detailed information by sharing an additional SCR by request.

I consent to my additional SCR being shared.

Yes

Further information can be found; digital.nhs.uk/services/summary-care-records-scr.

Demographics

Main Spoken Language

Ethnic Origin Optional

Your Medical Details

Please confirm if you have, or have ever had, any of the following conditions.

Family Medical Details

Please comment if a member has suffered from Cancer, Heart Disease, Stroke, Diabetes, Asthma Optional

State relationship, disease, type, age

Do you have any current health problems

Yes

Please specify any current health problems

Do you have any past health problems?

Yes

Please specify any past health problems.

Do you have any allergies?

Yes

Please give details.

Medications

Please list all that you take (including over the counter or alternative treatments) or include a copy of your repeat prescription list. As a new patient you may need to make a routine appointment to see a GP before any medication can be issued. Patients are encouraged to request repeat medication online via the NHS APP, please nominate a pharmacy so we can send your prescription electronically.

Nominated Pharmacy Optional

Please list your medications Optional

Names of drug/medicine, Dose, Frequency and Why you take it

Cervical Smear Tests (women aged 25 and older only)

Date of last smear

Result Optional

Where was the test done? Optional

Date next smear

Alcohol Consumption

This is one unit of alcohol:

Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
1 small glass of sherry

Each of these is more than one unit:

Pint of regular Beer/Lager/Cider (2 Units)
Pint of Premium Beer/Lager/Cider (3 Units)
Alcopop or can/bottle of regular Lager (1.5 Units)
Can of Premium Lager/Strong Beer (2 Units)
Can of super strength lager (4 Units)
Glass of wine (2 Units)
Bottle of wine (9 Units)

How often do you have a drink containing alcohol?

Never Optional

Monthly or less Optional

2-4 times per month Optional

2-3 times per week Optional

4+ times per week Optional

How many units of alcohol do you drink on a typical day when you are drinking?

1-2 Optional

3-4 Optional

5-6 Optional

7-9 Optional

10+ Optional

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never Optional

Less than monthly Optional

Monthly Optional

Weekly Optional

Daily or almost daily Optional

Smoking

Have you ever been a smoker?

Smoker

Ex-smoker

Never smoked

How many do you smoke per day?

When did you stop?

Your doctors advise all smokers to stop, and free help to do so is available from the surgery, or online at www.bromley.gov.uk/stopsmoking

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

Bromley Connect our Primary Care Network (PCN)

South View Partnership is part of Bromley Connect our Primary Care Network (PCN) which means our patients have access to shared NHS medical services, please tick to consent you are happy to be referred as appropriate for appointments within our PCN at South View Partnership, London Lane or Dysart Surgery.

Patient Declaration

Please sign below as confirmation that all the information you have provided on this registration form is correct.

Signed

Date